DESCRIPTION (APPLICATION ABSTRACT): There is wide agreement that improving patient safety and avoiding medical error are critically important goals. Health professionals, realizing that threats to patient safety are ever- present, have developed a variety of approaches to achieve these goals and ensure that patients receive the best possible care. One important source of influence on these activities is the working conditions under which care is delivered. Changes in the context of care that may help or hinder health professionals include physical aspects of the work environment; temporal factors such scheduling, workload, and the pace of care; and social and organizational factors that support, or fail to support, teamwork, communication, and the personal and professional characteristics that are essential for good patient care. In earlier studies of nurses, physicians, case managers, and others we have observed examples of these "making sure" behaviors. We now propose to conduct an ethnographic study of health professionals that will explore the impact of working conditions on the ability to provide safe and effective patient care. The aims of the study are to: 1. Describe the practices currently employed by health professionals to ensure the best possible care. 2. Identify breakdowns in these practices and describe how health professionals recognize them, refer to them, respond to them, and learn from them. 3. Describe changes in working conditions that help or hinder health professionals in their efforts to provide safe and effective care. 4. Collaborate with ongoing quality improvement and patient safety activities to improve the recognition, description, and response to conditions that threaten patient safety and the quality of care. Our multidisciplinary team includes investigators with backgrounds in medical informatics, nursing expertise, medical anthropology, and cognitive ethnography. The study will focus on the interdisciplinary care of acutely ill patients in intensive care units, and their transitions across settings. Subjects will include myriad health professionals with direct patient care responsibility, such as nurses, physicians, pharmacists, trainees, and care managers, and will also include patients and family members whose participation is essential to ensuring appropriate patient care.